Antibiotic Prophylaxis for Dental Patients at Risk for Infection - AAPD

[Pages:7]BEST PRACTICES: ANTIBIOTIC PROPHYLAXIS

Antibiotic Prophylaxis for Dental Patients at Risk for Infection

Latest Revision

2022

How to Cite: American Academy of Pediatric Dentistry. Antibiotic prophylaxis for dental patients at risk for infection. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric

Dentistry; 2022:500-6.

Abstract

This best practice offers recommendations regarding antibiotic prophylaxis to minimize or eliminate transient bacteremia in at-risk dental patients undergoing invasive dental procedures. Evidence supporting the efficacy and use of antibiotic prophylaxis is limited among children. Considering the potential to contribute to antibiotic-resistant microorganisms and possible risk of adverse events, prudence is needed when determining whether prophylaxis is necessary. Antibiotic prophylaxis is warranted for some patients with cardiac conditions and compromised immunity when undergoing dental procedures that involve the manipulation of gingival tissue or the periapical region of teeth or perforation of oral mucosa. While recommendations for certain conditions are discussed within the document, consultation with the patient's physician is recommended for management of other patients potentially at risk due to immune compromise, indwelling vascular catheters or shunts, or implanted devices. Dentists should be familiar with current evidence-based antibiotic prophylaxis recommendations, and specific antibiotic regimens aimed at the microorganisms mainly implicated in infective endocarditis are included.

This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and Scientific Affairs to offer updated information and guidance on antibiotic prophylaxis for dental patients at risk for infection.

KEYWORDS: PREMEDICATIONS, ANTIBIOTICS, ANTIBIOTIC PROPHYLAXIS, ENDOCARDITIS, ANTIMICROBIAL RESISTANCE

Purpose

The American Academy of Pediatric Dentistry (AAPD) recognizes that numerous medical conditions predispose patients to bacteremia-induced infections. Prophylactic antibiotics are recommended when patients with a high risk of adverse outcomes from bacteremia and infection undergo invasive oral/ dental procedures. These recommendations are intended to help practitioners make decisions regarding antibiotic prophylaxis for dental patients at risk.

Methods

Recommendations on antibiotic prophylaxis for dental patients at risk for infection were developed by the Clinical Affairs Committee, adopted in 19901, and last revised in 20192. This revision is based on a review of Prevention of Infective Endocarditis: Guidelines from the American Heart Association3, Infective Endocarditis in Childhood: 2015 Update: A Scientific Statement From the American Heart Association4, the American Dental Association (ADA) report The Use of Prophylactic Antibiotics Prior to Dental Procedures in Patients with Prosthetic Joints5, and the 2021 guideline on Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From

? the American Heart Association6. It also included PubMed /

MEDLINE database searches using key terms: infective endocarditis (IE), bacteremia, antibiotic prophylaxis, and dental infection. Articles were evaluated by title and/or abstract and relevance to dental care for children, adolescents, and those with special health care needs. Two hundred forty-three

articles met these criteria. When data did not appear sufficient or were inconclusive, recommendations were based upon expert and/or consensus opinion by experienced researchers and clinicians.

Background Bacteremia (bacteria in the bloodstream) is anticipated following invasive dental procedures and can lead to complications in an immunodeficient patient.7,8 High-risk cardiac disease, immunosuppression, and immunodeficiencies may compromise one's ability to fight simple infection. The rationale for antibiotic prophylaxis is to reduce or eliminate transient bacteremia caused by invasive dental procedures.9,10

Antibiotic usage may result in the development of resistant organisms.11 Utilization of antibiotic prophylaxis for patients at risk does not provide absolute prevention of infection. Postprocedural symptoms of acute infection (e.g., fever, malaise, weakness, lethargy) may indicate antibiotic failure and need for further medical evaluation.

ABBREVIATIONS AAPD: American Academy of Pediatric Dentistry. ADA: American Dental Association. AHA: American Heart Association. CIED: Cardiovascular implantable electronic device. GI: Gastrointestinal. GU: Genitourinary. IE: Infective endocarditis. VGS: Viridans group Streptococcal.

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The decision to use antibiotic prophylaxis should be made on an individual basis. Some medical conditions that may predispose patients to postprocedural infections12 are discussed below. This list is not intended to be exhaustive; rather, the categorization should help practitioners identify children who may be at increased risk. If a patient reports a syndrome or medical condition with which the practitioner is not familiar, it is appropriate to discuss the risk and susceptibility to bacteremia-induced infections with the child's physician prior to any invasive dental procedures.

To date, randomized controlled clinical trials supporting the efficacy and use of antibiotic prophylaxis are limited, especially in the pediatric population. Many recommendations are based on expert consensus.4,6,10,13-16 A study found 80 percent of preprocedural antibiotic prescriptions unnecessary as risk-factors were not present, highlighting a concern regarding the appropriateness of prescribed prophylaxis.17 Conservative use of antibiotics helps minimize the risk of developing resistance to current antibiotic regimens.3,18-20 Given the increasing number of organisms that have developed resistance to antibiotic regimens, as well as the potential for an adverse anaphylactic reaction to the drug administered21, antibiotic/antimicrobial stewardship and the judicious use of antibiotics for the prevention of IE or other distant-site infections are critical for safe and effective care.6,11,17,18 While use of antibiotic prophylaxis is indicated for certain patients undergoing invasive dental procedures, the prevention of oral disease by maintenance of good home care habits and regular dental care is considered more important.6,22 This may prevent the frequent need for the use of antibiotic therapy and, thus, decrease the risks of resistance and adverse events related to use of antibiotics.9,16,23

Recommendations

Antibiotic prophylaxis for patients at the highest risk of adverse outcomes from bacteremia-induced infections is recommended with certain dental procedures3,4,6,7,9,16,24 and should be directed against the most likely infecting organism. Antibiotic stewardship and judicious use are integral to preventing adverse reactions and resistance. Table 1 shows the recommended antibiotic regimen for at-risk patients undergoing invasive procedures, with amoxicillin as the first choice.6,10 Recent changes to the American Heart Association (AHA) guidelines have removed the use of clindamycin due to frequent and severe reactions.6 Clindamycin has been associated with significant adverse drug reactions related to community-acquired Clostridium difficile infections.21 Doxycycline is recommended as an alternative for patients unable to tolerate a penicillin, cephalosporin, or macrolide (Table 1).6 Short-term use (less than 21 days) of doxycycline had not been associated with tooth discoloration in children under eight years of age.25-27 Antibiotic prophylaxis should be given 30-60 minutes prior to the procedure; however, it can be given up to two hours after a dental procedure.6 A different class of antibiotics is indicated if the patient is already on oral antibiotic therapy or has an allergy or anaphylactic reaction.6 If unsure of a reported history of an allergic reaction,

consultation with an allergy specialist and skin testing can help determine severity of allergic reactions and course of antibiotic regimen.6 If the patient is receiving parenteral antimicrobial therapy for IE or other infections, the same antibiotic can be continued for the dental procedure.6 If possible, elective procedures should be delayed 10 days after completion of short course antibiotic therapy.6 When procedures involve infected tissues or are performed on a patient with a compromised host response, additional doses or a prescribed pre- and postoperative course of antibiotics may be necessary.

Patients with cardiac conditions The AHA has published guidelines for the prevention of IE and reducing the risk of producing resistant strains of bacteria.3,6 IE is an example of an uncommon but life-threatening complication resulting from bacteremia. The incidence of pediatric admissions due to IE was between 0.05 and 0.12 cases per 1000 admissions in a multicenter study of United States children's hospitals from 2003-2010.4 Although there is no high-quality data showing mortality from or frequency of viridans group streptococcal (VGS) infective endocarditis in children, there also has been no convincing evidence of an increase in these cases among high-risk patients since the publication of the 2007 AHA guidelines.6,10,28

Only a limited number of bacterial species have been implicated in resultant postoperative infections; viridans group streptococci, Staphylococcus aureus and Enterococcus species are the main microorganisms implicated in IE.3,4,29 Enterococcal and other organisms such as Haemophilus species, Aggregatibacter species, Cardiobacterium hominis, Eikenella corrodens, and Kingella species are less common.4 When compared to dental procedures, routine daily activities such as toothbrushing, flossing, and chewing contribute more to the incidence of bacteremia.4 Thus, focus for preventing IE has shifted from antibiotic prophylaxis to an emphasis on oral hygiene and the prevention of oral diseases with regular dental care.4,6,9,14-16,24

A summary of key findings and suggestions by the AHA 2021 scientific statement writing group are outlined in Table 2.

The AHA guidelines recommend antibiotic prophylaxis prior to certain dental procedures (Table 3) for patients with the highest risk of adverse outcomes from VGS IE (Table 4).6,20 Comorbidities such as obesity, diabetes, cardiopulmonary disease, vascular disease, hemodialysis, lack of access to tertiary hospitals, or immunosuppression affect the morbidity and mortality of patients with IE.7,20 Global consensus with regards to the benefit of antibiotic prophylaxis for prevention of IE is lacking.6,9,16,24,28

Children with cyanosis with specific periodontal concerns may have an increased risk of IE.3,4,6 At-risk patients with poor oral hygiene and gingival bleeding after routine activities (e.g., toothbrushing) have shown an increased incidence of bacteremia as a measure for risk of IE.3,29 These patients and their parents need to be educated and motivated to maintain personal oral hygiene, including flossing and regular professional

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Table 1. ANTIBIOTIC REGIMENS FOR A DENTAL PROCEDURE REGIMEN: SINGLE DOSE 30 TO 60 MINUTES BEFORE PROCEDURE

Situation

Agent

Adults

Children

Oral

Amoxicillin

2 g

50 mg/kg

Unable to take oral medication

Ampicillin OR Cefazolin or ceftriaxone

2 g IM or IV 1 g IM or IV

50 mg/kg IM or IV 50 mg/kg IM or IV

Allergic to penicillin or ampicillin --oral

Cephalexin* OR

Azithromycin or clarithromycin OR

Doxycycline

Allergic to penicillin or ampicillin Cefazolin or ceftriaxone and unable to take oral medication

2 g 500 mg 100 mg

1 g IM or IV

50 mg/kg 15 mg/kg < 45 kg, 2.2 mg/kg > 45 kg, 100 mg

50 mg/kg IM or IV

Clindamycin is no longer recommended for antibiotic prophylaxis for a dental procedure. IM indicates intramuscular; and IV, intravenous.

* Or other first-or second-generation oral cephalosporin in equivalent adult or pediatric dosing.

Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillin or ampicillin.

Table 2. SUMMARY OF FINDINGS AND SUGGESTIONS

Key findings

VGS IE is much more likely to develop as a result of transient VGS bacteremia attributable to routine daily activities such as chewing food and toothbrushing than from a dental procedure. An exceedingly small number of cases of VGS IE could be prevented by AP for a dental procedure, even if prophylaxis is 100% effective. If AP for a dental procedure is effective in preventing a very small number of cases of VGS IE, it should be suggested only for those patients with the highest risk of adverse outcome from VGS IE. There is no convincing evidence of an increased frequency of or morbidity or mortality from VGS IE in patients at low, moderate, or high risk of adverse outcome since publication of the 2007 document. AP for a dental procedure is not suggested solely on the basis of an increased lifetime risk of acquisition of VGS IE

Suggestions

AP for a dental procedure that involves manipulation of gingival tissues, periapical region of teeth, or perforation of the oral mucosa is suggested only for patients with the highest risk of adverse outcome from VGS IE. Maintenance of good oral health and regular access to dental care are considered more important to prevent VGS IE than AP for a dental procedure. We suggest that patients have biannual dental examinations when such care is available. Shared decision making is important between patients and health care providers. There may be instances when a health care provider and a patient disagree with the suggestions in the 2021 scientific statement. In these cases, the health care provider should be familiar with and understand the 2021 suggestions to adequately inform patients of the risks and benefits of AP for a dental procedure so that an informed decision may be made.

AP indicates antibiotic prophylaxis; IE=Infective endocarditis; VGS=Viridans group streptococcal.

Table 3. DENTAL PROCEDURES AND AP

AP suggested All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.

AP not suggested Anesthetic injections through noninfected tissue, taking dental radiographs, placement of removable prosthodontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of primary teeth, and bleeding from trauma to the lips or oral mucosa.

The antibiotic regimens suggested for prophylaxis for a dental procedure in patients at a high risk of adverse outcome from viridans group streptococcal infective endocarditis are shown in Table 1. AP indicates antibiotic prophylaxis.

All tables reprinted with permission. ? 2021 American Heart Association, Inc. Circulation 2021;143(20):e963-e978. Erratum in: Circulation 2021;144(9):e192. Available at: "".

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Table 4. AP FOR A DENTAL PROCEDURE: UNDERLYING CONDITIONS FOR WHICH AP IS SUGGESTED

Prosthetic cardiac valve or material Presence of cardiac prosthetic valve Transcatheter implantation of prosthetic valves Cardiac valve repair with devices, including annuloplasty, rings, or clips Left ventricular assist devices or implantable heart

Previous, relapse, or recurrent IE

CHD

Unrepaired cyanotic CHD, including palliative shunts and conduits Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by transcatheter during the first six months after the procedure Repaired CHD with residual defects at the site of or adjacent to the site of a prosthetic patch or prosthetic device Surgical or transcatheter pulmonary artery valve or conduit placement such as Melody valve and Contegra conduit

Cardiac transplantation recipients who develop cardiac valvulopathy

AP for a dental procedure not suggested

Implantable electronic devices such as a pacemaker or similar devices Septal defect closure devices when complete closure is achieved Peripheral vascular grafts and patches, including those used for hemodialysis Coronary artery stents or other vascular stents CNS ventriculoatrial shunts Vena cava filters Pledgets

AP=indicates antibiotic prophylaxis; CHD=congenital heart disease; CNS=central nervous system; and IE=Infective endocarditis.

Table reprinted with permission. ? 2021 American Heart Association, Inc. Circulation 2021;143(20):e963-e978. Erratum in: Circulation 2021;144(9):e192. Available at: "".

preventive dental care, and to be discouraged from getting tattoos or piercings.3,6,14-16,23,24 Professional prevention strategies should be based upon the individual's assessed risk for caries and periodontal disease.30

In addition to those diagnoses listed in the AHA guidelines, patients with a reported history of injection drug use may be considered at risk for developing IE.20 Consultation with the patient's physician may be necessary to determine susceptibility to bacteremia-induced infections.

Antibiotics are recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa for cardiac patients with the highest risk for adverse outcomes from IE3,6 (Tables 3 and 4). Specific antibiotic regimens can be found in Table 3. Practitioners and patients/ parents can review the entire AHA guidelines in the AHA Circulation archives6 (available at " 0000969") for additional background information as well as discussion of special circumstances (e.g., patients already receiving antibiotic therapy, patients on anticoagulant therapy).

Patients with shunts, indwelling vascular catheters, or

medical devices

The AHA found no convincing evidence that microorganisms associated with dental procedures cause infection of cardiovascular implantable electronic devices (CIED) and nonvalvular devices at any time after implantation.6,29,31 The infections occurring after device implantation most often are caused by Staphylococcus aureus and coagulase-negative staphylococci or other microorganisms that are non-oral in origin but are associated with surgical implantation or other active infections.29,32 The AHA does not recommend antibiotic prophylaxis for prosthetic cardiovascular devices such as CIED, septal defect closure devices, peripheral vascular grafts and patches, central nervous system ventriculoatrial shunts, vena cava filters and pledgets. (Table 4) Consultation with the child's physician is recommended for management of patients with nonvalvular devices.

Ventriculoatrial (VA), ventriculocardiac (VC), or ventriculovenus (VV) shunts for hydrocephalus were considered at risk of bacteremia-induced infections due to their vascular access, while ventriculoperitoneal (VP) shunts were not deemed vulnerable.31,33 Antibiotic prophylaxis is no longer recommended for patients with VA and VP shunts.6,33 If concerned, consultation with the child's physician is recommended for management of patients with vascular shunts.

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Table 5. MANAGEMENT OF PATIENTS WITH PROSTHETIC JOINTS UNDERGOING DENTAL PROCEDURES 5

Reprinted with permission. Copyright ?2015, American Dental Association. J Am Dent Assoc 2015;146(1):11-16.e8. Publisher by Elsevier Inc. All right reserved. "".

Patients with compromised immunity

Noncardiac patients with a compromised immune system may be at risk for complications of bacteremia and distant site infection following invasive dental procedures. Existing evidence does not support the extensive use of antibiotic prophylaxis; prophylaxis should be limited to immunocompromised patients and those at high risk for adverse outcomes from distant site infection.23 Consultation with the patient's physician is recommended for management of patients with a compromised immune system. High-risk patients who should be considered for use of prophylaxis includes, but is not limited to, those with6,14,15,22,31:

1. immunosuppression* secondary to:22,34 a. human immunodeficiency virus (HIV); b. severe combined immunodeficiency (SCIDS) and other primary immunodeficiency diseases; c. neutropenia and other neutrophil-related disorders (e.g., severe congenital neutropenia, leukocyte adhesion deficiency, Ch?diak-Higashi syndrome); d. cancer chemotherapy, immunosuppressive therapy and/or radiation therapy; or e. hematopoietic stem cell or solid organ transplantation.

2. history of head and neck radiotherapy.22,34 3. autoimmune disease (e.g., juvenile arthritis, systemic

lupus erythematosus). 4. sickle cell anemia.35,36 5. asplenism, status post splenectomy, or complement

deficiencies.22

6. chronic high-dose steroid usage. 7. uncontrolled diabetes mellitus. 8. medication-related osteonecrosis of the jaw

(MRONJ).37,38 9. hemodialysis.

Patients with prosthetic joints Given the lack of evidence and recognizing the increase in antibiotic resistance and adverse drug reactions, antibiotic prophylaxis prior to dental procedures is no longer recommended for patients with a history of total joint arthroplasty or prosthetic joint infections.5,17,39 (Table 5) If unsure of medical history or risk, consultation with the child's physician is recommended for invasive dental management.5,31,39,40

References 1. American Academy of Pediatric Dentistry. Antibiotic chemoprophylaxis for pediatric dental patients. Boston, Mass.: American Academy of Pediatric Dentistry; 1990. 2. American Academy of Pediatric Dentistry. Antibiotic prophylaxis for dental patients at risk for infection. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2019:416-21. 3. Wilson W, Taubert KA, Gevitz M, et al. Prevention of infective endocarditis: Guidelines from the American Heart Association--A Guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology,

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Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116(15): 1736-54. E-published April 19, 2007. Available at: " CULATIONAHA.106.183095#". Accessed September 22, 2022. Erratum in Circulation 2007;116(15):e376-e7. 4. Baltimore RS, Gweitz M, Baddour LM, et al. Infective endocarditis in childhood: 2015 update: A scientific statement from the American Heart Association. Circulation 2015;132(15):1487-515. 5. Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners?A report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2015;146(1):11-6. 6. Wilson WR, Gweitz M, Lockhart PB, et al. Prevention of viridans group streptococcal infective endocarditis: A scientific statement from the American Heart Association. Circulation 2021;143(20)e963-e978. Available at: ". 0000000000000969". Accessed March 26, 2022. Erratum in: Circulation 2021;144(9):e192. 7. Lockhart PB, Brennan MT, Kent ML, Norton JH, Weinrib DA. Impact of amoxicillin prophylaxis on the incidence, nature, and duration of bacteremia in children after intubation and dental procedures. Circulation 2004; 109(23):2878-84. 8. Roberts GJ, Jaffrey EC, Spract DA, Petrie A, Greville C, Wilson M. Duration, prevalence and intensity of bacteremia after dental extractions in children. Heart 2006; 92(9):1274-7. 9. Daly CG. Antibiotic prophylaxis for dental procedures. Aust Prescr 2017;40(5):184-8. 10. Laufaurie GI, Noriega LA, Torres CC, et al. Impact of antibiotic prophylaxis on the incidence, nature, magnitude, and duration of bacteremia associated with dental procedures: A systematic review. J Am Dent Assoc 2019;150 (11):948-59. 11. Centers for Disease Control and Prevention. Antimicrobial resistance. About antimicrobial resistance: A brief overview. December, 2021. Available at: ". drugresistance/about.html". Accessed January 24, 2022. 12. Buonavoglia A, Leone P, Solimando AG, et al. Antibiotics or no antibiotics, that is the question: An update on efficient and effective use of antibiotics in dental practice. Antibiotics (Basel) 2021;10(5):550. 13. Glenny AM, Oliver R, Roberts GJ, Hooper L, Worthington HV. Antibiotics for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database System Rev 2013; 4(10):CD003813. Available at: ". library.adelaide.edu.au/10.1002/14651858.CD003813 pub4". Accessed March 8, 2022.

14. Cahill TJ, Dayer M, Prendergast B, Thornhill M. Do patients at risk of infective endocarditis need antibiotics before dental procedures? BMJ 2017;358:j3942.

15. Cahill TJ, Harrison JL, Jewell P, et al. Antibiotic prophylaxis for infective endocarditis: A systematic review and meta-analysis. Heart 2017;103(12):937-44.

16. National Institute for Health and Care Excellence. Context In: Prophylaxis against infective endocarditis: Antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. 2008. Updated July 8, 2016. London: NICE. Available at: "". Accessed January 24, 2022.

17. Suda KJ, Calip GS, Zhou J, et al. Assessment of the appropriateness of antibiotic prescriptions for infection prophylaxis before dental procedures, 2011 to 2015. JAMA Netw Open 2019;2(5):e193909.

18. Fluent MT, Jacobsen PL, Hicks LA. Considerations for responsible antibiotic use in dentistry. J Am Dent Assoc 2016;147(8):683-6.

19. Watters W, Rethman MP, Hanson NB, et al. Prevention of orthopaedic implant infection in patients undergoing dental procedures. J Am Acad Orthop Surg 2013;21(3): 180-9.

20. Baddour LM, Shafiyi A, Lahr BD, et al. A contemporary population-based profile of infective endocarditis using the expanded Rochester Epidemiology Project. Mayo Clin Proc 2021;96(6):1438-45.

21. Thornhill MH, Dayer MJ, Prendergast B, Baddour LM, Jones S, Lockhart PB. Incidence and nature of adverse reactions to antibiotics used as endocarditis prophylaxis. J Antimicrob Chemother 2015;70(8):2382-8.

22. Squire JD, Gardner PJ, Moutsopoulos NM, Leiding JW. Antibiotic prophylaxis for dental treatment in patients with immunodeficiency. J Allergy Clin Immunol Pract 2019;7(3):819-23.

23. Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): The Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Eur Heart J 2009;30(9):2369-413.

24. National Heart Foundation of New Zealand Advisory Group. Guideline for the prevention of infective endocarditis associated with dental and other medical interventions. Auckland: National Heart Foundation of New Zealand. December, 2008. Available at: ". t.nz/vdb/document/312". Accessed March 8, 2022.

25. Todd SR, Dahlgren FS, Traeger MS, et al. No visible dental staining in children treated with doxycycline for suspected Rocky Mountain Spotted Fever. J Pediatr 2015;166(5):1246-51.

References continued on the next page.

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26. American Academy of Pediatrics. Tetracyclines. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. In: Kimberlin DW, ed, Barnett ED Lynfield R, Sawyer MH, associate eds. 32nd ed. Elk Grove Village, Ill.: American Academy of Pediatrics; 2021:978-1-61002578-2.

27. Stultz JS, Eiland LS. Doxycycline and tooth discoloration in children: Changing of recommendations based on evidence of safety. Ann Pharmacother 2019;53(11): 1162-6

28. Dayer MJ, Jones S, Prendergast B, Baddour LM, Lockhart PB, Thornhill MH. Incidence of infective endocarditis in England, 2000-13: A secular trend, interrupted time-series analysis. Lancet 2015;385(9974):1219-28.

29. Baddour LM, Epstein AE, Erickson CC, et al. Update on cardiovascular implantable electronic device infections and their management. Circulation 2010;121(3):458-77.

30. American Academy of Pediatric Dentistry. Periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. The Reference Manual of Pediatric Dentistry. Chicago, Ill: American Academy of Pediatric Dentistry; 2022:253-65.

31. Lockhart PB, Loven B, Brennan MT, Fox PC. The evidence base for the efficiency of antibiotic prophylaxis in dental practice. J Am Dent Assoc 2007;138(4):458-74.

32. Hong CHL, Allred R, Napenas JJ, Brennan MT, Baddour LM, Lockhart PB. Antibiotic prophylaxis for dental procedures to prevent indwelling venous catheter-related infections. Am J Med 2010;123(12):1128-33.

33. Baddour LM, Bettman MA, Bolger AF, Bolger A, Ferrieri P. Nonvalvular cardiovascular device-related infections. Circulation 2003;108(16):2015-31.

34. American Academy of Pediatric Dentistry. Dental management of pediatric patients receiving immunosuppressive therapy and/or head and neck radiation. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:507-16.

35. Tate AR, Norris CK, Minniti CP. Antibiotic prophylaxis for children with sickle cell disease: A survey of pediatric dentistry residency program directors and pediatric hematologists. Pediatr Dent 2006;28(3):332-5.

36. Hsu LL, Fan-Hsu J. Evidence-based dental management in the new era of sickle cell disease: A scoping review. J Am Dent Assoc 2020;151(9):668-77.e9.

37. Montefusco V, Gay F, Spina F, et al. Antibiotic prophylaxis before dental procedures may reduce the incidence of osteonecrosis of the jaw in patients with multiple myeloma treated with bisphosphonates. Leuk Lymphoma 2008;49(11):2156-62.

38. Yarom N, Shapiro CL, Peterson DE, et al. Medicationrelated osteonecrosis of the jaw: MASCC/ISOO/ASCO Clinical Practice Guideline. J Clin Oncol 2019;37(25): 2270-90.

39. Rethman MP, Watters W, 3rd, Abt E, et al. The American Academy of Orthopedic Surgeons and the American Dental Association clinical practice guideline on the prevention of orthopaedic implant infection in patients undergoing dental procedures. J Bone Joint Surg 2013; 95(8):745-7.

40. Berbari EF, Osmon DR, Carr A, et al. Dental procedures as risk factors for prosthetic hip or knee infection: A hospital-based prospective case-control study. Clin Infect Dis 2010;50(1):8-16. Erratum in Clin Infect Dis 2010; 50(6):944.

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